Health care forecast

Health and Human Services: Getting ready for launch — By 2014, health insurance exchanges need to be ready to go in all 50 states, and HHS will have to run many of them on its own — and set up “partnerships” to help other states get theirs off the ground. The department will also have to persuade as many states as possible to expand Medicaid now that doing so is optional.

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Outlook: Watch for HHS to find new ways to demonstrate flexibility — on both exchanges and Medicaid — as it tries to get maximum participation from the states. But that won’t satisfy many red-state governors, and HHS will have to find new ways to fill the gaps in states that want nothing to do with Obamacare.

States: Making up their minds — The states now have more time to plan their exchanges. They can tell HHS whether they’ll run their own exchange as late as Dec. 14, and they can wait until Feb. 15 to say if they want to set up a “partnership” exchange with the federal government. But now they have to decide whether to do either of those — or just let HHS run the whole show. They also need to decide whether to expand their Medicaid programs, although there’s no hard deadline for that.

Outlook: Political pressure on red-state governors may lead them to back away from setting up health exchanges, but some could revisit the issue down the road. And while there will be some holdouts on Medicaid, most will probably find some way to expand — especially if HHS is open to some partial expansions.

Congress: Medicare deal, Obamacare oversight — Congress will still be the stage for any long-term deal on Medicare savings. But with divided control once again, the Republican House won’t be able to repeal the health care law, and the Democratic Senate won’t be able to make any major fixes if things go wrong. That leaves oversight as the one major activity Congress can perform.

Outlook: Expect lots of House hearings — and more subpoenas — over Obamacare and a Medicare Advantage quality demonstration program. There could also be targeted attacks on the law, such as moves to repeal unpopular pieces — like the Independent Payment Advisory Board or the medical device tax — or to overturn rules like the one that allows tax credits for people who get insurance through the federal exchanges.